Healthcare Provider Details

I. General information

NPI: 1366060386
Provider Name (Legal Business Name): MAKAYLA BROOKE GUNTER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAKAYLA BROOKE GRESHAM

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4968 ELK RIVER RD S
ELKVIEW WV
25071-9644
US

IV. Provider business mailing address

4968 ELK RIVER RD S
ELKVIEW WV
25071-9644
US

V. Phone/Fax

Practice location:
  • Phone: 304-965-6661
  • Fax:
Mailing address:
  • Phone: 304-965-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4521
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number11861
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: